ValuHost | Private Label Reseller Plans

Fully Managed Dedicated Server
Customer Information
Please fill out completely
First Name
Last Name
Company
Address
City
State/Province
Zip/Postal Code
Country
Phone
Primary Email

Account Information

Processor
Memory
Hard Drive(s)
Bandwidth
Price
Operating System
Control Panel
Billing Information
Please fill out completely
Name on Card
Card Number	e.g. 4567-3423-4322-1245
Card Type
Expiration Date

Optional Information
How Did You Find Us?
If Customer Referral	Name or domain of customer
Notes

Processing this form is your agreement, to the charge of your selected plan.
Your Credit Card Will Read Charge As Montage Inc.

We do not tolerate credit card fraud, which is a felony. If it is determined that an attempted order is fraudulent, we will report all information (including your IP address) to the FBI, at http://www.ifccfbi.gov/